Bacterial Vaginosis - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  --
Last review: 01/03/2016  
Next review: 05/12/2020  
Clinical Guideline
ID: 2245 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Bacterial Vaginosis



Preferred option


Bacterial vaginosis

Oral Metronidazole electronic Medicines Compendium information on Metronidazole is as effective as topical treatment 1A+ but is cheaper.

Less relapse at 4 wks 3A+  with7 days oral metronidazole than 2g stat

Pregnant2A+/breastfeeding: avoid 2g stat 3A+

Treating partners does not reduce relapse 5B+

Metronidazole electronic Medicines Compendium information on Metronidazole  1,3A+
400mg BD PO
7 days 1A+ or 2g stat
Metronidazole electronic Medicines Compendium information on Metronidazole 1A+
0.75% vaginal gel
5g applicator nocté
5 nights

Clindamycin electronic Medicines Compendium information on Clindamycin
2% cream
5g applicator nocté
7 nights 1A+

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Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  6. Limit prescribing over the telephone to exceptional cases.
  7. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. Co-Amoxiclav (Amoxicillin-Clavulanate), quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  8. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  9. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.
  10. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.

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Record: 2245
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Bacterial Vaginosis

Target patient group:
Target professional group(s): Primary Care Doctors
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.

Evidence base

Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.

Study design


Good recent systematic review of studies


One or more rigorous studies, not combined


One or more prospective studies


One or more retrospective studies


Formal combination of expert opinion


Informal opinion, other information


Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

STI screening

  1. National Chlamydia Screening Programme here
  2. BASHH and MedFASH. Standards for the management of sexually transmitted infections (STIs). British Association of Sexual Health and HIV and the Medical Foundation for AIDs and Sexual Health. 2010.

Bacterial vaginosis

  1. Joesoef MR, Schmid GP, Hillier SL. Bacterial vaginosis: review of treatment options and potential clinical implications for therapy. Clin Infect Dis 1999;28(suppl 1):S57-S65. Pooled data from five RCTs found no significant difference between cumulative cure rates 5-10 days after finishing treatment for metronidazole 400mg BD for 7 days (86%), intravaginal metronidazole 5g BD for 5 days (81%) or intravaginal clindamycin 5g at night for 7 days (85%).
  2. McDonald HM, Brocklehurst P, Gordon A. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 1. Accessed 23.09.14. RATIONALE: Pooled data from 10 RCTs indicated that both oral and intravaginal antibiotics are effective at eradicating bacterial vaginosis in pregnant women. Oral antibiotics compared with placebo (seven trials, n=3244) OR 0.15, 95% CI 0.13 to 0.17. Intravaginal antibiotics compared with placebo (three trials, n=1113) OR 0.27, 95% CI 0.21 to 0.35.
  3. Joesoef MR, Schmid GP. Bacterial vaginosis: review of treatment options and potential clinical implications for therapy. Clin Infect Dis 1995;20(Suppl 1):S72-S79. RATIONALE: The 2g single dose is less effective than the 7-day course at 4-week follow up. When data from studies that only directly compared the two dose regimens were pooled, the cumulative cure rates 3-4 weeks after completion of treatment were 62% for the single-dose regimen and 82% for the 7-day regimen (p < 0.005).
  4. UKTIS. Use of metronidazole in pregnancy. The UK Teratology Information Service. 2008. (Tel: 0844 892 0909) RATIONALE: The available data (almost exclusively based on oral treatment) does not indicate an increased risk of adverse fetal effects associated with metronidazole use during pregnancy. The manufacturer advises avoidance of the 2g stat regimen during pregnancy.
  5. BASHH. National guideline for the management of bacterial vaginosis. British Association for Sexual Health and HIV. 2006. Accessed 23.09.14. RATIONALE: No reduction in relapse rate was reported from two studies in which male partners of women with BV were treated with metronidazole, tinidazole, or clindamycin.

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Document history

LHP version 1.0

Related information

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